Today marks the 50th anniversary of the 1963 civil rights march on Washington, D.C. at which Martin Luther King, Jr., delivered his famous “I Have a Dream” speech. As a family medicine researcher interested in understanding, explaining, and fighting against racial health inequalities, I also think it’s important to note that Martin Luther King also noted the injustice of racial health inequities. In a speech in 1966, King said that “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” Racial health inequities are a special instance of social inequities and social injustice in general.

In commemorating the historic 1963 March on Washington and the movement that it was a part of, we need to be mindful of the fact that much work is left to be done to achieve the goals of the civil rights movement.

Yes, de jure racial segregation was defeated; however, de facto racial segregation continues to this very day. The conditions of life for the Black community improved some in the wake of the civil rights movement led by Dr. King. However, we still have a long way to go, as our communities remain plagued by segregated, low-quality schools, racially segregated neighborhoods, devastating unemployment, and poor housing. Below, for example, is a map depicting racial segregation in U.S. schools today. Municipalities throughout the U.S. enforced racial segregation in the schools since the founding of public education systems. Their constitutional right to do so was upheld by the U.S. Supreme Court in Plessy v. Ferguson, 163 U.S. 537 (1896). However, in the landmark case, Brown v. Board of Education, 347 U.S. 483 (1954), the Supreme Court overruled Plessy and forbad state and local governments from practicing racial segregation. Despite this legal change, some public schools today are more racially segregated today than when Brown was decided in 1954. School segregation even increased in the 1990s. (Jeffrey Rosen, “The Lost Promise of School Integration”, New York Times, April 2, 2000, A1, 5.) As the 2000 map of school segregation below illustrates, black/white segregation is highest in counties with high black populations. (Compare with the 2000 census map of the distribution of blacks in the United States.)

Why has the law failed to undo the segregation that was originally caused by the law? The most obvious reason is that racial segregation of neighborhoods remains the norm in the U.S., as demonstrated in the city maps on this site. To the extent students attend neighborhood schools, they are likely to have few classmates of other races. But the courts, too, have played a role–initially by acquiescing in state resistance to desegregation, more recently by attacking the tools states use to achieve integration.

A couple of months prior to the August 28th March on Washington, King spoke at a massive rally of hundreds of thousands in Detroit. I did not attend that demonstration; however, as a young junior high school student in Detroit, the march had a huge impact on me nevertheless. King’s speech in that Detroit rally ring as true now as they did then:

“And so we must say, now is the time to make real the promises of democracy. Now is the time to transform this pending national elegy into a creative psalm of brotherhood. Now is the time to lift our nation from the quicksands of racial injustice to the solid rock of racial justice. Now is the time to get rid of segregation and discrimination. Now is the time.

“And so this social revolution taking place can be summarized in three little words. They are not big words. One does not need an extensive vocabulary to understand them. They are the words ‘all,’ ‘here,’ and ‘now.’ We want all our rights, we want them here, and we want them now.”

Last week marked the 40th anniversary of the Roe v. Wade decision in the U.S. Supreme Court, which declared laws prohibiting abortion violated a woman’s constitutional rights. The Supreme Court justices also ruled that states could regulate abortion in the interests of women’s health or to protect a “potential human life” starting at the end of the pregnancy’s first trimester.
Seven out of 10 people in the United States support a woman’s right to an abortion. However, right-wing and liberal opponents of this right have used the states’ ability to regulate abortions to eat away at abortion rights over the last four decades. According to the Guttmacher Institute, states enacted more than 43 new restrictions on access to abortion in 2012. These restrictions came on top of the previous year’s record-high 92 restrictions.
Legal challenges, alone, will not keep abortion safe and legal. Supporters of women’s rights need to mobilize to defend women’s constitutional rights and reproductive health.

Gun violence is a public health danger. We need to do something about it. However, all the pundits are barking up the wrong tree. In the debate on gun control laws and regulations broiling since the tragic and horrific murders in Newtown, Connecticut, one very important point gets ignored in the major media: the biggest, most dangerous, and deadliest perpetrator of gun violence in the world is the U.S. government. According to the Bureau of Investigative Journalism,U.S. drones have murdered 176 children in Pakistan alone. That’s more than 9 times the number of children murdered in Newtown. (Upwards of 1,005 civilians in Pakistan, Yemen, and Somalia have been brutally cut down by U.S. drone strikes.) Why hasn’t there been a public outcry over these killings?

The New York Timesreported recently that President Obama personally orders these drone strikes. While Adam Lanza, the shooter in the Newtown murders, was clearly a sociopath, Barack Obama is portrayed as a completely sane, thoughtful – excuse me, brilliant – leader “defending U.S. interests.” Heck, the man even got the Nobel Peace Prize!

The U.S. government murders children and other civilians every day. I’m outraged by these killings, and you should be outraged, too. The lives of U.S. children are no more precious than those of Pakistani, Afghani, Yemeni, and Somalian youth.

U.S. culture is a culture of violence. If the man personally responsible for ordering attacks that killed hundreds of children gets the Nobel Peace Prize, should we be surprised that others find it reasonable to attempt to do the same? This culture of violence condones unspeakable crimes against humanity as the unfortunate consequences – “collateral damage” – of the just pursuit of “U.S. interests.” The U.S. government has a long, bloody history in which millions of civilians, including children, have been murdered – from the carpet-bombing of Germany, to the dropping of atomic bombs on Hiroshima and Nagasaki, to wars in Korea, Vietnam, Iraq, and Afghanistan.

The U.S. government metes out violence inside this country, as well. Let’s start with the genocide of the Native American population. U.S. troops have been used to crush workers’ strikes and put down uprisings in African-American communities. Local police forces are known for their deadly brutality, especially toward African-American and Latino communities.

The most important and effective gun control we could enact would be to disarm the U.S. government. Now, that would be a major advance for global public health. It would save millions of lives!

Campaign to end AIDS epidemic in African-American community needs major social changes

Huge racial and ethnic disparities in the incidence of AIDS continue to exist, although there may be signs that the relative disparity in AIDS diagnoses (the ratio of minority to white diagnosis rates, for example) is narrowing. In a study published in the American Journal of Preventive Medicine last fall, researchers reported that, between 2000 and 2009, disparities in the rate of AIDS diagnoses decreased between all racial and ethnic groups except for those between African-American and white men aged 13-24. In this group, disparities increased.

Although racial and ethnic disparities in AIDS incidence are decreasing slightly, they still exist. Among 13-24 year-olds in 2009, non-Hispanic Blacks had an incidence of 22/100,000, Hispanics had a rate of 5.5/100,00, and whites had a rate of 1.2/100,000. For age 25-44, the comparable numbers are 79, 27, and 9. For age 45-64, 71,24, and 7. And for age 65 and older, 13, 6, and 1. Clearly, huge racial and ethnic disparities in AIDS incidence continue exist, and they seem to be widening among young men.

Very few state governments offer dental coverage in their Medicaid programs, and those that do are slashing those benefits. Recently, Governor Pat Quinn of Illinois cut $1.6 billion out of the state’s $15 billion Medicaid budget, reducing the state’s adult dental coverage to emergency tooth extractions only. In a further assault on Illinois’ poor, the state slapped a new co-payment on prescription drugs. About half the states in the country only cover dental emergencies and pain relief.

In the ramp up to broadening Medicaid coverage in 2014 under the Affordable Care Act (ACA), many state governments are looking for ways to cut their benefits. The ACA prohibits states from tightening eligibility for Medicaid coverage. However, there are no restrictions on cutting “optional” benefits such as dental, vision, and prescription coverage. State governments across the country are using this loophole to deny billions of dollars in benefits to the nation’s poor.

Unfortunately, even in states where Medicaid pays for preventive (cleaning) and restorative (fillings and root canals) dental care, finding dentists who accept the government insurance is next to impossible. Here, in Charlottesville, no dentists take Medicaid. Poor working people are forced to go to the local free clinic, where the waiting list is months long, to obtain dental care. In many rural and minority communities, no dentists are even available. Access to oral health care is even more difficult than access to other physical health care.

Poor oral health leads to disease in the mouth, teeth, and gums; it also is a major cause of other systemic chronic illnesses. Poor oral health increases the risk of various lung diseases, has been linked to an increased incidence of diabetes, and is associated with an increased incidence of pre-term birth of low-weight babies (who are at increased risk of chronic illness in childhood).

We need more dentists and more dental hygienists. Physicians, nurse practitioners, and physician assistants should be trained to provide preventive dental services and emergency dental care. And, of course, provide health care — including oral health care — to everyone as a basic human right through establishing a federally funded, national health service.

We have a shortage of physicians – especially primary-care physicians. The ones we have are maldistributed being concentrated in urban areas. This physician shortage will worsen with the implementation of the Affordable Care Act, according to a piece in the July 29, 2012 issue of The New York Times. The Times cited the Association of American Medical Colleges, which estimates that in 2015 the United States will be short 62,900 physicians. By 2025, the AAMC says this shortfall will be twice as high, owing to Medicaid expansion and increased demand from an aging population. According to the Times, “Even without the health care law, the shortfall of doctors in 2025 would still exceed 100,000.”

The Department of Health and Human Services recommends that a given region have 60 to 80 primary care doctors per 100,000 residents, and 85 to 105 specialists. In many areas of the country the ratio of physicians to the population falls well short of that mark.

Even when poor people find a physician, it’s difficult to get care. Fewer than half of primary care clinicians were accepting new Medicaid patients as of 2008, according to the Times. The ACA calls for adding some 30 million people to the Medicaid accounts. Those primary-care clinicians who see Medicaid patients are going to be deluged and ill-prepared to meet this surge.

The whole debate around the so-called health care reform has centered on expanding coverage and lowering costs. However, the real problem facing millions of working people in this country – especially, minority and rural populations – is access to care.

Insurance coverage is a necessary but insufficient means to obtaining medical care. We need a single-payer, national health care system so that no one is turned away from clinical care owing to cost. However, we also need to increase the number of primary-care physicians and redistribute them, covering rural and minority communities that are sorely lacking in physician services.

The following policy brief by Joel Albers on the Affordable Care Act is well worth the read. As I noted in an earlier post, the U.S. Supreme Court decision upholding the ACA is a pyrrhic victory. The analysis that follows outlines some possible positive effects of the law and ways in which those of us who support a single-payer health system might take advantage of the new regulations.

Hi Everybody,
The U.S. Supreme Court two weeks ago upheld the Patient Protection and Affordable Care Act of 2010, Pubic Law 111-148 also known as the Affordable Care Act (ACA) of 2010. The law, enacted on March 23, 2010, consists of 10 Titles (sections), totaling 1024 pages (greater than 2000 pages including related statutes). The following analysis brief focuses on Title I : “Quality, Affordable Health Care for All Americans” (141 pages), which i believe is the most crucial section as it creates the overall framework for changes compared to current law. The two most important sections within Title I are: “Health Insurance Market Reforms” and “Individual and Group Market Reforms”. Feel free to distribute this to other individuals and lists.

Does the ACA of 2010 bring improvements over current law ?

There are some widely reported features of the ACA that look good on paper as follows:

-dependent coverage up to age 26
-no denials of coverage due to pre-existing conditions,
-federal premium subsidies for those with income up 400% of the federal poverty line (FPL),
-coverage of preventive tests with no co-pays,
-lifting of lifetime limits on coverage
-expansion of Medicaid from 100% of FPL to 133% FPL, etc.

Some, but not all of the harsh “risk rating” to determine premiums for enrollees have been eliminated, including health status, occupation, and other demographic and geographic characteristics. Premiums determined by risk rating based on age have been retained yet at no greater than a 3:1 ratio. Public pressure to solve the health insurance and health care crisis, particularly by single-payer advocates combined with the plummeting of the economy in 2008, combined to bring about some of these ostensible changes and improvements.

What will be the net effect of the ACA of 2010 over the short and longer term?

Strategically, I believe we can work with it, mainly due to the cooperative health insurance pools provision mentioned at the conclusion of this brief. In the short-term, it will improve access and some benefits; yet, longer term, the built-in loopholes create opportunities for the industry to circumvent the progress and create fewer and more powerful insurance companies. Yet for now, the ball is at least in the industry’s court.

Like the more than 2,000 page Dodd-Frank Banking law, the ACA will further consolidate control of health care into fewer and even more powerful health insurance companies, (like banks). United Health Group, Wellpoint, Aetna, Humana, Cigna will gain further access to markets previously limited to largely state and regional health insurers across the U.S. (see ACA section 1333, p. 206 (b) “Authority for Nationwide Plans”, subsection 1(A) states:
” the issuer of the plan may offer the nationwide qualified health plan in the individual or small group market in more than 1 State”). Currently, little to no competition in state markets exists as the dominant insurer already controls the majority of the market share (by enrollment) when taken in aggregate and individually(in most states) across the 50 states (Source: How competitive are state insurance markets ? (Kaiser Family Foundation, Oct 2011). Note that the The McCarran-Ferguson Act of 1945 also provides that federal anti-trust laws do NOT apply to the “business of insurance”. This has allowed for substantial consolidation (buyouts,mergers, aquisitions, in the health insurance industry. The largest U.S. health insurer, United Health Group’s revenues now exceed $100 billion due to takeovers of other health insurers from coast to coast since 1991.

Also, health insurance companies are NOT REQUIRED to sell health insurance policies within the Health Insurance Exchange. (see p.182,SEC. 1312. “CONSUMER CHOICE”. (d) ” Empowering consumer choice”.– (1) “Continued operation of market outside exchanges —Nothing in this title shall be construed to prohibit— (A) a health insurance issuer from offering outside of an Exchange a health plan to a qualified individual or qualified employer”). This invalidates the premise of the “Exchange,” which is to standardize policies and create a competitive market by allowing consumers to compare prices, benefits, and quality thereby forcing insurers to compete. For decades just the opposite has occurred– monopoly– and more of the same is expected under the ACA. In addition, the “essential benefit” or “minimum essential coverage” (p248) assures that health insurance companies can continue deceptive marketing practices beyond the “essential benefit”, particularly to woo healthier patients and avoid those with pre-existing conditions, as is clearly the case in the Medicare HMO Advantage program (Medicare Part C). It also creates a two-tiered system in which those operating outside the Exchange are back to “wild west” conditions, while further fragmenting health care.

Although under the ACA, insurance would be “guaranteed issue” and consumers are “mandated” to PURCHASE private insurance without denial of coverage due to pre-existing conditions health insurers are not mandated to SELL policies in any particular market and can drop all enrollees by exiting a market (typically designated by a given county or zip code area). Insurers can change coverage from year to year, potentially exclude a body part, or restrict enrollment periods.

ACA bolsters private insurance industry

Essentially, the ACA law maintains the private, market-based health insurance system and includes 1. individual mandate, 2.regulations 3.subsidies and 4. adjusted community (not individual) premium rating. And although the benefits mentioned above are welcome, and look good on paper, for each benefit, the complicated 2000 plus page law builds-in loopholes, cost-shifting, and “actuarial equivalence” (these are insurance companies, what else would one expect ?). So for example, although lifetime limits on coverage, typically at $5 million, were lifted at the backend, on average, consumers will be paying a 25% co-insurance on the front end for one of four policies from which to select on the Exchange. However, “actuarial equivalence” means the insurers can distribute this so-called “cost sharing” over not just coinsurance, but also deductibles, and copayments, etc. as long as the total cost for plan-to-plan is “actuarial equivalent”. Thus, rather than standardizing and simplifying the system, the ACA further complicates and fragments it, as caused by a failed managed care micromanagement approach.

Note also that many specific decisions and rulemaking still need to be established, and much of that is in the hands of The Secretary of Health and Human Services, Kathleen Sebelius, former Commissioner of Insurance for the state of Kansas. It is these Commissioners whom comprise the National Association of Insurance Commissioners, who created many of the state model legislation that served as a precursor to the ACA. The NAIC is the organization which defines terms like “pre-existing condition”, and “guaranteed issue”. Moreover, enforcement of many of the regulations such as reviewing premium rates and rate increases greater than 10%, and rebating of surpluses, are already lax in most states, including a revolving door of regulators from the industry itself. There is no sense of greater accountability within the ACA as there are too many “moving parts”.

One provision, however, can give us a foothold toward a publicly-funded single-payer approach, the creation of cooperative health insurance pools within each state which can expand to other states (p187 section 1322, “Member-run health insurance issuers”). But we only won this provision as an alternative to the scrapped public option (expansion of the Medicare pool) of which there was tremendous public pressure to include in 2009. By becoming an insurer, albeit one that is self-funded, member-run and cooperative, we can take advantage of some of the provisions that would accrue to the industry, like premium subsidies, tax credits, and keep funds within our own communities, and end exorbitant CEO salaries, and profiteering.

Joel Albers

Addendum: for more practical specific questions regarding how the ACA will affect you as an individual, household, or employer, pls email or call contact info below.

Less than half of Americans get the preventive clinical services we need. Clinical care aimed at preventing HIV infection, cancer, stroke, and heart attacks is delivered on a regular basis to only half the population, according to the Centers for Disease Control and Prevention (CDC).

Moreover, there are huge inequities in who does receive this care. African-Americans, Latinos, and other minorities are less likely than whites to receive appropriate clinical preventive services. For example, about 46% of white patients with hypertension have their blood pressure under control, compared with 32% of Mexican-American patients. Racial and ethnic disparities in the delivery of clinical services may result from physicians’ unconscious biases toward these patients. However, the greatest proportion of this inequities no doubt stems from the unequal distribution of health care services and other problems of access.

Physicians, nurse practitioners, and other health care providers tend to be located in urban and more affluent communities. Inner-city ghettoes, barrios, and other working-class or rural communities have a dearth of health care services. In addition, the populations in these communities are the very same ones with little or no health insurance, which means that — even when available — health care is not accessible.

We need a single-payer, national health care system, with universal coverage. We need to incent health care providers to locate in minority, rural, and working-class communities. And we need to develop the housing, education, and industrial resources of these communities to address all the social determinants of their health.

We have nothing to celebrate with the U.S. Supreme Court’s decision to uphold the Affordable Care Act. The ACA is pain management and palliative care for a terminally ill health system. The U.S. health system needs a truly revolutionary transformation, and the ACA seeks to shore it up by pumping billions of taxpayer dollars into it. What we really need to do it s to pull the plug on a fee-for-service, capitalist market-driven system, substituting universal health care provided by a single-payer, national health care system.

The ACA is actually a boondoggle for the insurance industry. More than $400 billion in taxpayer funds will be channeled to private insurers through government subsidies of private premiums. The federal government will pump billions more into the U.S. health system through expanding Medicaid to some 16 million poor people currently uninsured.

Meanwhile, insurers will exploit loopholes to dodge the law’s restrictions on their misbehaviors. For instance, the limit on administrative overheads predictably will elicit accounting gimmickry. For example by relabeling some insurance personnel as “clinical care managers.” While insurers are prohibited from “cherry picking” — selectively enrolling healthy, profitable patients — they’ve circumvented similar prohibitions in the Medicare health maintenance organizations (HMOs).(2) The ban on revoking policies after an individual falls ill similarly replicates existing but ineffective state bans.

The so-called individual mandate, requiring uninsured people to buy insurers’ defective health insurance policies is a boon to the insurance companies. Nothing in the ACA contains any more teeth than existing state regulations on the insurance industry. Therefore, we can expect that the insurers will continue to find loopholes and other ways around restrictions on the denial of the human rights of their policyholders. We can expect the insurers to find ways to “cherry pick” those they cover – selectively enrolling only the most healthy and profitable patients. They will continue to find ways around restrictions against revoking policies after an individual falls ill. The restrictions on this practice in the ACA are no different than those that exist in many states in which the private insurers have found a way to avoid circumvent them.

It’s infuriating that the ACA is touted as a mechanism for universal health coverage. Under this act, some 23 million people will remain uninsured in 2019. Millions of undocumented workers will be denied health coverage under the law. These working people will be denied adequate health care coverage by the ACA, and the so-called safety-net hospitals upon which they rely for their care will lose $36 billion in funding because the law mandates an end to federal government funding for indigent care.

Meanwhile, employers are forcing workers onto high-deductible health insurance plans; in effect, shifting health care costs onto working people themselves. Many people, as a result, are unable to pay their medical bills, with a serious illness sending many into bankruptcy. At present, illness and medical bills account for 62% of all bankruptcies – and three-quarters of those bankruptcies occur in people who have insurance.(1)

A similar health care “reform” was instituted in Massachusetts in 2006, and it was clearly a model for the ACA. What have been the results? In the first 2 years after the Massachusetts health reform was instituted, the state’s health care costs increased 15% — twice the national rate.(2) The physician workforce was woefully inadequate to meet the increased demand for primary-care and other services, and the state began cutting back on services.

Let’s face it: the ACA, drafted in close collaboration with the pharmaceutical and insurance industries, funnels billions of taxpayers’ dollars into the coffers of big business. To win support for this conservative legislation, Obama and the Democratic Party threw in a few sobs – expansion of Medicaid, $1 billion a year for community health centers, no denial of coverage for pre-existing conditions, and coverage of dependents until age 26. We shouldn’t buy into a plan designed to enrich the insurance and pharmaceutical industries in exchange for these modest reforms. Let’s really transform health care in the United States. We need a non-profit, single-payer, national health insurance program that covers everyone in the country. Anything short of that is putting a Band-Aid on a festering wound.

Primary-care physicians are in short supply in Black, Latino, and other minority communities.

Last month, Medical News Today discussed a study that showed that African Americans and Latinos are more likely than whites or Asians to live in neighborhoods that are low-income, inner-city, or rural, and have access to few or no primary care physicians.

The article reported on a study published in Health Services Research that found that African Americans and lower-income Latinos are more likely to live in neighborhoods with few or no primary care physicians. Dr. Darrell J. Gaskin, lead author and deputy director of the Hopkins Center for Health Disparities Solutions at Johns Hopkins Bloomberg School of Public Health, said, “What this says to us is that we really need to encourage physicians to locate in these areas.” The study used data collected by the U.S. Census and American Medical Association from 2000 to 2006. An area with a shortage of health professionals was defined as having one or no physician per 3,500+ people in an area. The results found African Americans and Latinos were 25.6 percent and 24.3 percent, respectively, more likely to live in an area with few or no primary care physicians, compared with 13.2 percent of whites and 9.6 percent of Asians.

In a health system based on fee-for-service payments to physicians and hospitals, the market will drive physicians and other clinicians away from communities with large numbers of uninsured, unemployed, and low-income people — in other words, working-class African-American, Latino, and other minority neighborhoods; as well as rural areas, even those with predominantly white population. As Gaskin noted, “You can’t pay physicians less for a service under Medicaid and expect them to want to practice in that kind of area. We’re talking about areas where doctors won’t be able to practices because they can’t sustain themselves.”

In addition to this maldistribution of the physician workforce resulting from capitalist market forces, I believe that African Americans and Latinos also lack primary-care health services because of racial discrimination. One of the main drivers of this discrimination is the continued residential segregation of these communities. The June 2012 issue of Health Services Research is dedicated to exploring health disparities in the United States and includes an article on the effect of racial residential segregation on health.

Financial incentives, such as loan repayment, increased payment for Medicaid, or increased payment for services provided to underserved communities, would help shift the distribution of the clinical workforce. However, a better solution would be eliminating the fee-for-service payment structure. Pay clinicians for keeping whole populations or communities healthy, rather than paying us for doing things to people.